Publication Date 01/04/2014         Volume. 6 No. 3   
Information to Pharmacists

Editorial

From the desk of the editor

Business is tight!
Cash flow has evaporated!
The PGA calls for unity while simultaneously dismembering the business of consultant pharmacists.
The federal government continues to strip massive funds from the PBS to the extent that it is gasping for air.
Oh, and I forgot, the Revive Clinic thinks that pharmacists cannot vaccinate patients in community pharmacies ( It is actually a warehouse pharmacy group trying to destabilise the market here to push fellow-pharmacists off balance by supporting the Revive group).
Even wage-earning pharmacists have discovered that they have not had a rise in their pay over the past five years

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An Evidence-Based Conversation Between Ken Harvey, Gerald Quigley and Neil Johnston

Neil Johnston

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Neil Johnston is a pharmacist who trained as a management consultant. He was the first consultant to service the pharmacy profession and commenced practice as a full time consultant in 1972, specialising in community pharmacy management, pharmacy systems, preventive medicine and the marketing of professional services. He has owned, or part-owned a total of six pharmacies during his career, and for a decade spent time both as a clinical pharmacist and Chief Pharmacist in the public hospital system. He has been editor of i2P since 2000.

Editor’s Note:
I recently received an email from Dr Ken Harvey the well-known academic from Latrobe University, who is trying to reform some aspects of the TGA, particularly in relation as to how drugs and complementary medicines are registered, and the quality of evidence used to support claims of efficacy.
It’s a subject that has gained traction since the beginning of the year, and there are a range of viewpoints that need to be sorted out so that coherent policies can be formulated that would be broadly supported by all health professionals (not just mainstream health professionals).
About the same time I received a communication from Gerald Quigley talking about the clinical and educational resources that exist within the Society of Hospital Pharmacists of Australia.
I reflected on both these communications and decided to publish them in a positive fashion, hopefully to create an ethical and clinical direction for community pharmacy.

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Ken Harvey is highlighting the problem that the Pharmacy Guild of Australia ignited by not thinking through a proposal for a clinical promotion in conjunction with Blackmore’s Laboratories that involved the blanket recommendation of certain nutritional supplements with particular drugs prescribed for patients.
The PGA was heading in a suitable direction, but the method could not be considered ethical.
i2P offered comment at that time (even sympathy for the PGA which was unusual for us!).

Ken has unearthed a community pharmacy that seems to be following the original PGA promotional method, a method that has been universally condemned.

What was needed (and still is) was a pharmacist qualified in clinical nutrition responding to a patient request and taking a full history of all circumstances. Preferably, this pharmacist should have a degree of “arms-length” from the pharmacy owner, but that is not an absolute necessity.
After a full investigation of the patient’s circumstances and a need is found for nutritional supplements, then a recommendation can be ethically made.

In Ken’s actual experience, this service was being provided by an unqualified sales person in the manner of “would you like coke and fries with that?”


It has often been suggested by i2P that a range of pharmacist health practitioners specialising in lifestyle disorders should be available as a standard primary care service in a clinical setting. Some pharmacies have experimented with nurses in a pharmacy clinical setting, but as yet have not supported qualified pharmacists in this role.

Why not?
It’s a long overdue development. Otherwise we are likely to see more unsuitable equivalents being provided, similar to that uncovered by Ken Harvey.

What follows is Ken’s letter to i2P and following on from that are comments by Gerald Quigley for professional service pharmacists to take on board.

Dear Neil

Yesterday (May 1, 2012) I went to the Hawthorn Pharmore Pharmacy to get a repeat prescription of my wife’s simvastatin ‘script dispensed.   
I was intrigued when a young female sales assistant recommended that BioCeuticals coenzyme Q10 should be purchased with the ‘script and provided a handout (as illustrated).

She had a very convincing and clearly well-scripted sales talk; does your wife lack energy or have sore muscles? Did you know that "statins" decrease Co Q10 levels? Did you know that your heart needs this important supplement if you are taking "statins"?

I was unkind enough to point out that this issue of “companion sales” had produced a lot of adverse publicity for pharmacy,

And the NPS and The Age/Ken Harvey) had evaluated the evidence and were not convinced, She said she knew nothing of this.

So I returned with the NPS and additional literature and asked for the pharmacist-in-charge to make contact. Regrettably, this has yet to happen. 

I remain most disappointed by this pharmacy-consumer interaction.

Sincerely,

Ken

Dr Ken Harvey, Adjunct Associate Professor, School of Public Health, LaTrobe University http://medreach.com.au VOIP (03) 90293697 | Mobile +614 1918 1910 | Fax: +613 9818 1875

Postscript
: Subsequently a pharmacist from Pharmore Pharmacies did respond to my concerns and I took up her offer to make contact by telephone. She mentioned that Pharmore sales assistants had been trained by BioCeuticals which Pharmore believed was a reputable company and she felt the NPS advice was merely one opinion amongst others that she referenced.

Gerald Quigley’s comments follow and we would welcome reader comments as to how we might aggregate all input into a useful format to encourage community pharmacists to deliver optimum professional services.

Hi Neil,

For your consideration please:I have discovered a superb new educational resource!It’s called “Pharmacy Practice and Research” or “The Official Journal of the Society of Hospital Pharmacists of Australia”
And what a monthly read it is!!

I’ve never actually worked in a hospital pharmacy, and my exposure to that area of practice has been limited to ensuring that patients of mine could safely make the transition from the ward to their own home. This common issue is sometimes very challenging for a variety of reasons.On joining SHPA, I was seeking re-stimulation of my “illness” education, because my focus is on “wellness” education.
And I haven’t been disappointed at all.

I was supplied with four back issues of this Journal, and I’m astounded at the relevance of many of the articles to our roles in community Pharmacy.
If you want value for your educational and information dollar, I can’t recommend these journals more highly.

I’ve discovered things that other organizations don’t tell me.
I’ve learned about the issues of being admitted to hospital on a weekend.

I’ve discovered what a “Lipid Pharmacist” is, and their role in running a lipid clinic. What possibilities does that open up in service based pharmacies?
Perhaps new opportunities and new clinical practice.

And why not include a “nutrition” pharmacist, reviewing medicines and nutrient depletions?
In a rather frightening article, I read about unanswered health-related questions in community Pharmacy. Scary stuff, when you consider that we feel that we are doing the best by our patients. This is evidence based material clearly showing that we aren’t!

Or the impact on direct-to-consumer advertising of prescription medicines on the internet?
What ramifications might that have?

Is SHPA a hidden gem? Might be and worth considering for any professional pharmacy practitioner.

I have some comments on Ken Harvey’s exchange at the Pharmore Pharmacy. The Pharmore group I might add take their professional role very, very seriously, and in many instances are well in front of others in patient care.

At The International Science of Nutrition in Medicine and Healthcare Conference in Melbourne (where I chatted to Ken, and was attended by my count, THREE pharmacists), key research was given that “statins” deplete CoQ10, thereby affecting cognition.
GP questioning after that session showed naivety, but a real willingness to understand and advise. In other words, “to take responsibility”.

So do we pharmacists take responsibility or not? Do we have the balls? Or do we just hide behind “the evidence”. Well here’s evidence! But do we need a bit, some, lots or from what source before we accept and apply the results??
Or is it evidence that has to pass some other authority for a tick of approval before we act?
Are we very, very selective in what evidence we are happy with?

The process at the pharmacy in question was great, but far too aligned to “coke and fries”. The product concerned was BioCeuticals brand of CoQ10, “a practitioner only” product!
So where was the pharmacist who simply doesn’t understand what a ‘practitioner only’ product actually entails?? No doubt doing his low-margin, rapid turnaround dispensing with the resultant minimal “supply” fee!

It’s like my “bacon and egg comparison”. We can be involved or committed. In bacon and eggs, the chook is involved, but the pig is committed!

If I was started on a statin, and I was over 50, and I wasn’t given information from the pharmacist as to the potential effects of a statin on cognition, I’d be really annoyed. In fact, if my cognitive abilities decreased, and I wasn’t advised, and the pharmacist might reasonably be expected to know, might that be a reason to seek to speak to a legal advisor?  

Cheers Neil,

Regards,

Gerald

Editor summary:

1. All parties to this conversation appear to be in agreement that the process at the Pharmore Pharmacy was not appropriate.

2. Excluding Ken Harvey, we also agree that the Pharmore group is a highly professional operation that appears to have slipped up on this occasion. Hopefully it is only a “one-off” incident.

3. Everybody has a notion of what constitutes “evidence”. In the case of official Pharmacy, nobody seems to argue a case for the evidence they are prepared to take responsibility for.
It certainly was confused in respect of the PGA/Blackmore’s issue.
It is a base that is definitely wider than promoted mainstream medical evidence – and even that differs according to which branch of medicine is involved.

4. i2P would even go one step further and claim that even when legitimate evidence is available to support the claims for coenzyme Q10, mainstream medicine practitioners simply ignore it, because they lack the experience to make a judgement for this type of treatment or are irrationally and strongly biased against any form of complementary medicine.
Further, i2P have uncovered reported incidence of fraudulent mainstream evidence that has caused us to rely more on our own clinical experience, rather than “toe” a mainstream medical party-line.

5. Pending clarification of legal issues, at least two of us agree that a patient may have an action against a pharmacist, if cognitive difficulties resulted from taking a prescribed “statin” without accompanying information and advice from that pharmacist regarding the use of coenzyme Q10.

Obviously, the evidence debate still has a long way to go before satisfaction sets in.
In conclusion, Gerald Quigley forwarded a comment that recently appeared in the March 2012 edition of the ACNEM Journal a GP reports:

“Throughout medical school, I was a big fan of evidence-based medicine, and I thought it was so convenient that almost everything a doctor needs to know is neatly summarized in the Australian Medicines Handbook and Therapeutic Guidelines.

Setting out to train in General Practice as I was I thought “what could possibly go wrong? The best available evidence is right there at my fingertips”.

How naïve was I? I soon discovered that clinical practice was more of an art than a science, and that evidence was much more than gaining confidence in one’s own clinical experience. Lowe and Brewster (2003. Evidence-based medicine and clinical practice. Journal of Paediatrics and Child Health. Vol 39, Issue 2 pp 145-146) point out that evidence is a synthesis of others’ experience with one’s own ie that the RCTs say in relation to one’s own clinical experience.

More often than not it is the combination of nutrients/anti-oxidants/doctor-patient interactions etc which make a treatment work, and this seldom equates to a double-blind RCT proving the effectiveness of single isolated factors."

That statement reflects the editor's personal belief, and I hope other pharmacists can rally behind that message and include it as part of their own perspective.

Return to home

Submitted by Anonymous on Mon, 18/06/2012 - 15:16.

“Excluding Ken Harvey, we also agree that the Pharmore group is a highly professional operation that appears to have slipped up on this occasion. Hopefully it is only a “one-off” incident.”

I would like to put my 2 cents in as a former Pharmore employee. I now left – so maybe some things have changed.

Pharmore had a number of policies while I was there regarding “companion sales”, as do many other pharmacy chains. Each member of the staff were given “targets” which they must reach each week – this basically a money target. If you reach your target you get a black (or red; I forget which) sticker against your name, below a red (or black) sticker, and above you get a GOLD STAR for all the staff to see. If you get a gold star average for the month you receive a monetary reward. Congratulations. If you don’t reach your targets, the whole staff will know about it. Shame on you.

If staff members do not reach their targets they were given training on how to sell products (approaching customers, etc…) and if that fails, you may get a warning.

Staff were also told to “up sale” – if the customer (and I use this word deliberately) wants a small pack of ibuprofen, talk them into getting the bigger one. That’s better; right?

There were also monthly targets for the whole store called “bombs” – you have to sell a given amount of a product line for that month. For example, one month we had to sell a certain amount of Neurofen, another we had to sell, you guessed it, co-enzyme Q10. If the store meets their store bombs target again they receive a monetary reward that the store can use towards their Christmas party, or washing windows, etc…

I agree that in some cases it is appropriate to recommend proven products to patients, it is part of our primary care job; for instance an emollient and soap-free wash for patients with dermatitis, or spacers for patients with asthma. However, what is happening at Pharmore and other pharmacy chains is completely different. Not only is it against AHPRA guidelines, but it is completely unethical.

Shop staff, although they have some basic training regarding pharmacy medications, will be more swayed by the managers tell them “YOU MUST SELL X” than any basic training they may have had. They are so swayed that I have had some shop staff recommend a "bombs" product to a patient when I had explicitly said it was not appropriate.

Dispensary staff were pressured also; and I’m 100% sure that a pharmacist cannot be told how to practice, and yet they are.

Giving monetary rewards for “selling” brings in a huge conflict of interest for staff members, as they can easily become more interested in selling products rather than looking out for patient interests.

As a pharmacist, I found this type of thing extremely difficult to reconcile with.

Unfortunately, this practice is wide spread in many pharmacies especially large chains. Due to money constraints pharmacies are almost forced to do anything to make ends meet.

However it can be done without this nonsense. I now work in a pharmacy where we are not forced to companion sale. Our prices might be higher, but that pays to have enough pharmacists and shop staff on hand at all times. And it means that we are not forced into unethical money making strategies employed elsewhere.

I believe that the Pharmacy Board and Guild need to work together to help stop these practices, but also make ethical practice profitable for pharmacy owners.

Submitted by Dr Ken Harvey on Mon, 14/05/2012 - 11:17.

Gerald Quigley said, "At The International Science of Nutrition in Medicine and Healthcare Conference in Melbourne, key research was given that “statins” deplete CoQ10, thereby affecting cognition. If I was started on a statin, and I was over 50, and I wasn’t given information from the pharmacist as to the potential effects of a statin on cognition, I’d be really annoyed".

The paper Gerald referred to was titled, "Statins, CoQ10 and cognition, are they related?"
In a study of 340 adults the Swinburne University author noted
(a) their findings indicated there MAY (my emphasis) be subtle cognitive defects in statin users;
(b) it is not known whether statin related cognitive impairments could be due to reduced CoQ10 levels caused by statins and (c) a trial is underway to assess whether there were any cognitive benefits of giving CoQ10 to statin users.
Other recent research (not cited by the above author) has concluded:

"Statin use and type were marginally associated with cognitive impairment. After adjusting for known variables that affect cognition, no association was observed. No regional differences were observed. This large study (24 595 participants (7191 statin users and 17 404 nonusers) found no evidence to support an association between statins and cognitive performance." http://www.ncbi.nlm.nih.gov/pubmed/20513066

"Despite several reports of statin-associated cognitive impairment, this adverse effect remains a rare occurrence among the totality of the literature. If statin-associated cognitive impairment is suspected, a trial discontinuation can reveal a temporal relationship. Switching from lipophilic to hydrophilic statins may resolve cognitive impairment. The vascular benefits and putative cognitive benefits outweigh the risk of cognitive impairment associated with statin use; therefore, the current evidence does not support changing practice with respect to statin use, given this adverse effect" http://www.theannals.com/content/46/4/549.abstract .

In conclusion, NEVER regard conference presentations of unpublished work as definitive; always check the literature before making recommendations.

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